Timberwood Court Specialty Care Community

The Alleged Victim (AV) relies on the facility for his/her care and has a history of falls. According to an investigation, on or about, April 20, 2025, AV experienced a fall, resulting in a broken vertebra. The facility failed to implement interventions to mitigate the risk of injury due to AV's increase in falls. This failure is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care and has a history of falls. According to an investigation, on or about, March 8, 2025, AV experienced a fall, resulting in bruising to their right hip. The facility failed to implement interventions to mitigate the risk of injury due to AV's increase in falls. This failure is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) has history of elopement and exit seeking behaviors. According to an investigation, on or about September 1, 2024, AV eloped from the facility and was found in the parking lot behind the facility, placing AV at risk for serious harm. The facility failed to provide a safe environment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has history of elopement and exit seeking behaviors. According to an investigation, on or about September 1, 2024, eloped and was returned to the facility. Approximately thirty minutes after the first elopement, another resident contacted facility staff and reported that AV left the facility through a window in the resident’s room. AV was found in a neighboring yard, placing AV at risk for serious harm. The facility failed to provide a safe environment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about May 15, 2023, the Alleged Victim (AV) was discovered with a large bruise on his/her left thigh. AV is not a known fall risk, therefore, it is unknown how AV received this bruise. The facility failed to provide a safe environment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) had suffered a fall on March 20, 2023 and was transported to the hospital for his/her injuries. AV requires full staff assistance with mobility and transfers. On or about May 21, 2023, AV suffered another fall in his/her room while he/she was attempting to make his/her bed. AV fell while trying to grab his/her walker and fell to the ground, suffering a skin tear on his/her arm and head, along with an abrasion on his/her knee. The facility failed to properly care plan to ensure AV's safety from falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk with a history of falls. The facility failed to provide appropriate services according to Alleged Victim’s needs, relating to care planning and lack of appropriate interventions, to mitigate the risk of injury due to AV's increase in falls. According to an investigation AV experienced multiple falls between April 29, 2022, and September 7, 2022, which resulted in repeated unreasonable discomfort. This failure is a violation of resident rights, is neglect of care which constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. The AV is a known fall risk with a history of falls. According to an investigation, on or about August 1, 2022, AV was found on the floor in AV’s bathroom with a head injury. The facility failed to provide appropriate services according to Alleged Victim’s needs, relating to care planning and lack of appropriate interventions, to mitigate the risk of injury due to AV's increase in falls, which is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) was care planned to have cotton underwear on under his/her depends as he/she is allergic to depends. AV has been found on multiple occasions without the cotton underwear on, causing AV to have a rash in his/her private area, to which staff are to apply ointment regularly to assist with curing the rash. Staff do not consistently apply the ointment, and at time run out of AV's prescribed ointment for this rash. AV suffered pain and unreasonable discomfort due to the rash on AV's private area. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) was found multiple times with wet incontinence briefs and soiled with feces. AV also suffered skin breakdown with a rash under his/her breast. There is no documentation that AV received a shower on a consistent basis. The facility failed to provide AV with basic care and services, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about July 13, 2022, it was observed that the Alleged Victim (AV) suffered a bruise to his/her left buttock. It is believed that AV suffered this bruise from sitting on the toilet, although it is unknown which surface AV hit that caused the bruise. AV is known to sit down hard on the toilet when transferring him/herself. The facility failed to implement interventions to ensure the safety of AV while toileting. The facility failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about June 10, 2022, the Alleged Victim (AV) was found to have a bruise on his/her left hand. It is unknown how AV received the bruise, however, it is suspected that AV received the bruise from staff transferring AV with the hoyer lift, as AV is unable to assist with the transfer and staff were known to deviate from trained practices while transferring AV. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about May 15, 2022, the Alleged Victim (AV) suffered a fall in another residents room and was transported to the hospital for evaluation. AV was not listed as a fall risk on his/her care plan, however, AV had suffered multiple falls recently and his/her care plan was not updated. The facility failed to properly are plan, which a a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) is known to have aggressive behaviors towards staff and residents. Staff are to check W1 hourly and redirect W1 from other residents rooms. On or about April 23, 2022, W1 and the Alleged Victim (AV) were involved in an altercation where W1 pushed AV, and AV fell to the ground. AV was taken to the hospital and diagnosed with a broken hip. The facility's failure to properly care plan to ensure the safety of AV is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has a history of frequent falls. Between November 2021 and April 2022, AV suffered approximately 18 falls, 11 of those instances resulted in pain, injury or being sent out to the Emergency Room (ER). On or about April 22, 2022, it was noticed on AV that he/she had a golf ball sized bruise on his/her inner buttock, causing considerable pain. The next day AV was sent to the ER, and was found his/her bruise had grown in size. On April 24, 2022, AV was found to have a laceration on his/her head with dried blood found on the bathroom floor. The facility failed to implement reasonable interventions, properly care plan and have enough staff available to prevent AV's falls. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to ensure supervision and staff support regarding known behaviors related to Witness #1 (W1). An incident occurred between W1 and the Alleged Victim (AV) where W1 attempted to enter AV's room and ran over AV's feet with his/her walker, causing bruising to AV's ankle. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to ensure supervision and staff support regarding known behaviors related to Witness #1 (W1). An incident occurred between W1 and the Alleged Victim (AV) where W1 entered AV's room and attempted to remove AV's from his/her room by pulling on AV's arm, causing bruising. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) have a history of altercations. On or about January 15, 2022, AV and W1 were found in the community bathroom, W1 had a hold of AV's wrist and refused to let go, holding onto AV tighter. AV's wrists were red from the altercation. The facility failed to provide a safe environment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) has a known history of aggression and is to be monitored every 20 minutes and be in line of sight when he/she is in the common areas. On or about January 15, 2022, the Alleged Victim (AV) and W1 were found together in the bathroom alone, where W1 was being aggressive with AV. AV states that W1 grabbed him/her and hurt him/her. The facility failed to have interventions in place and properly care plan for W1 to ensure resident safety. The facilities failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) was known to have falls with injury. AV suffered several falls throughout the month of December with injury, ISP's were put into place to remind AV to call for assistance, however, these interventions were not person centered and effective to reduce AV's risk of falls. AV sustained at least 8 falls with injury during the month of December. The facility failed to provide person centered interventions to reduce the risk of AV's falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) moved into the facility on November 2, 2021, and it was noted that he/she had falls at his/her previous care setting, however, his/her care plan did not indicate any fall prevention. On or about November 16, 2021, AV suffered a bruise on his/her back, no investigation was completed by the facility to find the cause of the bruising, nor were any interventions put into place. On or about November 25, 2021, AV suffered a fall resulting in bruising and swelling to AV's face. The facility failed to properly care plan to ensure AV's safety, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to have a training program that includes methods to determine competency of direct care staff through evaluation, observation, or written testing. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to ensure the local law enforcement agency must be called first when the suspected abuse is believed to be a crime. The facility’s failure is a violation of Oregon Administrative Rules.

The facility’s failure to complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident to include supervision and support. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident and use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident and use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly, as required. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to follow Medication and treatment orders must be carried out as prescribed. The facility’s failure is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) relies on the facility for their care. AV has known behaviors of attempting to kick, pinch and bite staff. According to an investigation, on or about November 4, 2025, AV was found to be reaching for another resident. When AP2 attempted to move AV in AV’s wheelchair, AV placed their feet on the ground so the wheelchair could not be moved. AP2 continued to try and move AV, which caused AV to bite AP2. AP2 responded by open hand swatting AV on the upper arm. AV then reached for AP2 and AP2 forcefully removed AV’s hand. AV experienced unreasonable discomfort. AP2’s actions are a violation of resident rights, are considered neglect of care and constitute physical abuse. The facility failed to ensure care plans were followed and protect AV from physical abuse, which is a violation of Oregon Administrative Rules.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool. An investigation determined this is a violation of Oregon Administrative Rules.

The facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

The facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) relies on the facility for their care. According to an investigation, on or about July 9, 2025, Alleged Perpetrator 3 (AP) placed a mask on AV and restricted AV’s arms with a sheet. AP2’s actions are a violation of resident rights, are considered wrongful restraint and constitutes verbal abuse, resulting in loss of dignity. The facility failed to ensure a safe environment, which violates Oregon Administrative Rules. The allegation that Alleged Perpetrator 2 (AP2) wrongfully restrained AV was investigated and determined to be not substantiated.

The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request by the Department. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to consistently staff to the levels, intensity and qualifications indicated by the Acuity-Based Staffing Tool (ABST). Inconsistencies were identified between the staffing schedule and the data produced by the ABST. Facility is not currently staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) relies on the facility to provide a safe environment. According to an investigation, on or about March 7, 2025, the Alleged Perpetrator 2 (AP2) forcefully restrained the AV and removed them to their room against their will, which resulted in repeated unreasonable emotional discomfort and loss of personal dignity. AP2’s actions are a violation of resident rights, considered wrongful physical restraint, and constitutes abuse. The facility failed to protect AV from wrongful physical restraint, which is a violation of Oregon Administration Rules.

The facility failed to consistently staff to the levels, intensity and qualifications indicated by the Acuity-Based Staffing Tool (ABST). Inconsistencies were identified between the staffing schedule and the data produced by the ABST. Facility is not currently staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request by the Department. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to consistently staff to the levels, intensity and qualifications indicated by the Acuity-Based Staffing Tool (ABST). Inconsistencies were identified between the staffing schedule and the data produced by the ABST. Facility is not currently staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide a safe medication administration system for the Alleged Victim (AV). According to an investigation, AV failed to receive his/her medication as ordered. The failure is a violation of Oregon Administrative Rules.

The facility failed to provide a safe medication administration system for the Alleged Victim (AV). According to documentation, AV experienced no negative outcome. The failure is a violation of Oregon Administrative Rules. The allegation that Alleged Perpetrator 2 (AP2) neglected AV was investigated and determined to be not substantiated.

On or about May 27, 2023, Alleged Perpetrator #2 (AP2) was observed by staff yelling at the Alleged Victim (AV). AV appeared to be fearful and visibly upset by AP2's actions. AP2's actions are a violation of resident rights, is considered neglect of care and constitutes verbal abuse. The facility's failure is a violation of Oregon Administrative Rules.

On or about May 24, 2023, the Alleged Victim (AV) was heard yelling from his/her room. When staff went to AV's room, they found AV trapped in the hoyer lift which is stored in the shared bathroom. AV was very upset. Alleged Perpetrator #2 (AP2) acknowledged that he/she left AV in his/her bathroom to finish their business and told other staff members that he/she locked AV in his/her room because they were tired of dealing with him/her. AP2's actions are a violation of resident rghts, are considered neglect of care and constitutes involuntary seclusion.

The Alleged Victim (AV) requires full staff assistance for mobility. On or about May 24, 2023, AV blew his/her whistle to advise staff he/she needed assistance. When staff asked Alleged Perpetrator #2 (AP2) if he/she was going to assist AV, AP2 replied "no". AV was found in his/her bed with wet linens, claiming that AP2 would not assist AV with using the restroom. AP2's actions caused AV unreasonable discomfort. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure is a violation of Oregon Administrative Rules.

The facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents. On or about October 24, 2022, a staff performing med tech duties was also providing full care to his/her infant child in the medication room. The facility failure is a violation of Oregon Administrative Rules.

The facility failed to carry out medication orders as prescribed which is a violation of Oregon Administrative Rules.

The facility failed to carry out medication orders as prescribed

The facility failed to carry out medication orders as prescribed